Clinical Case: 37-Year-Old Female — Posterior Uterine Myoma (Leiomyoma), 24-Weeks Size

Diagnosis: Uterine Leiomyoma (Posterior Wall Myoma)

• Solid, firm, mobile pelvic mass
• 24-weeks uterine size
• Age 37 (reproductive age, premenopausal)

FIGO Classification

Clinical Features Supporting This Diagnosis

• Enlarged, irregularly shaped, firm, nontender uterus on bimanual examination — pathognomonic for fibroids
• Mobile — suggests no malignant infiltration or pelvic fixation
• Solid on USG — consistent with leiomyoma (vs. cystic ovarian mass)
• At 24-weeks size, this is a giant fibroid — one of the largest categories

Key Differential Diagnoses to Exclude

Investigations Required

1. Ultrasound (done) — confirm posterior wall location, assess vascularity with Doppler
2. MRI pelvis — gold standard for fibroid mapping; differentiates leiomyoma from LMS (enhancement pattern on Gd-DTPA); also detects adenomyosis
3. CBC — assess for anemia (heavy menstrual bleeding is common)
4. LFT/RFT, coagulation — preoperative workup
5. CA-125 — to help exclude ovarian malignancy (non-specific)
6. Endometrial biopsy — if abnormal uterine bleeding present
7. LDH and its isoenzymes — elevated in LMS; helps differentiate from degenerating fibroid

Symptoms to Elicit

• Heavy/prolonged menstrual bleeding (most common — from submucosal component or increased endometrial surface)
• Pelvic pressure, bulk symptoms
• Urinary frequency/urgency (anterior displacement of bladder)
• Constipation/tenesmus (especially with posterior myoma compressing rectum)
• Infertility or recurrent pregnancy loss
• Backache (posterior myoma compresses lumbar nerves)

Management

Patient is 37 years old → Fertility Preservation is a Priority

• GnRH agonists (leuprolide) — shrink fibroid size (15–40%), reduce uterine size from ~15 weeks → ~11 weeks; allow vaginal approach; treat preoperative anemia
• IV iron infusion if Hb <9 g/dL (more effective than oral iron — increases Hb by 3.0 vs 0.8 g/dL)
• Tranexamic acid / NSAIDs — for menorrhagia symptom control

Surgical (Definitive):

• Uterus-preserving, safe alternative to hysterectomy
• Case-controlled studies show less intraoperative injury with myomectomy vs. hysterectomy at similar uterine sizes (14–15 weeks); blood loss actually less with myomectomy (227 mL vs. 484 mL for hysterectomy)
• At 24-weeks size, laparoscopic approach has technical limitations → open myomectomy preferred
• Posterior myoma requires a posterior uterine incision; retroperitoneal dissection may be needed due to proximity to ureter/rectosigmoid

• Better for fibroids <10 cm / fewer than 3–4 fibroids
• Requires multilayer suture closure of myometrium; limited electrosurgery
• Risk of uterine rupture in future pregnancy if closure is inadequate

• Family complete and patient consents
• Severe symptoms unresponsive to conservative measures

• Non-surgical; reduces fibroid size by ~40%
• Not preferred if future fertility desired (evidence of reduced ovarian reserve and obstetric complications post-UAE)

Laparoscopic myomectomy technique: FIGO Type 2–5 leiomyoma being dissected and closed with multilayer suture — Berek & Novak's Gynecology

Specific Considerations for Posterior Myoma

Recurrence After Myomectomy

• Recurrence rate: approximately 27% at 5 years by ultrasound; symptomatic recurrence ~11%
• Higher in younger women and those with multiple fibroids
• GnRH agonists postoperatively may slow recurrence

Post-Myomectomy Pregnancy Counseling

• Uterine rupture risk in subsequent pregnancy: 0.47% with trial of labor after myomectomy
• Cesarean section is typically recommended if deep myometrial entry was made during myomectomy
• Risk increases if only single-layer closure was performed or electrocautery was heavily used